Several new guidelines were also presented at this year’s ESC Congress in Barcelona. Enclosed is an overview of recommendations from pulmonary embolism, myocardial revascularization, hypertrophic cardiomyopathy, aortic disease, and noncardiac surgery.
(ag) In Barcelona, on the one hand, the focus was on the management of pulmonary embolism. This condition is associated with high mortality and morbidity rates (15% of pulmonary embolism patients die in the first month, and 30% have a recurrence in the next decade). The Guidelines Update is based on important new evidence and includes three relevant changes.
First, the use of thrombolytics in normotensive pulmonary embolism patients is addressed using recent outcome data from clinical trials.
Second, risk stratification of pulmonary embolism patients is emphasized. For a patient-centered approach to treatment, one is critical. The guidelines include a clearer definition of intermediate-risk patients as part of this selective approach. In the update, the classification of pulmonary embolism severity was renewed. It takes into account both the risk associated with pulmonary embolism and the patient’s clinical status and comorbidity. For the first time, risk-adapted therapy recommendations based on this classification can also be found.
For patients at intermediate risk, the new guidelines do not recommend routine systemic thrombolysis as initial therapy because recent studies have shown that fibrinolysis can be withheld relatively safely with ongoing initial anticoagulation as long as no hemodynamic decompensation occurs.
Third, the guidelines expand the section on new oral anticoagulants in both the acute and long-term settings – this is due to numerous new studies from recent years. Experience with the new oral anticoagulants in the acute, long-term, and maintenance phases remains limited, but currently they can be considered safe and effective as a class of agents in all these therapeutic phases. The development of the new oral anticoagulants simplifies acute treatment in particular. According to the new guidelines, some selected patients (depending on prognosis and severity) can be treated as outpatients during this phase.
Myocardial revascularization
Myocardial revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is a crucial therapeutic principle in cardiology. The renewed ESC and EACTS guidelines provide an overview of who needs revascularization, which subgroups need revascularization and how (e.g., diabetic or renal insufficiency patients), and which approach is recommended in patients with stable coronary artery disease (CAD) and acute coronary syndrome (ACS). The update is based on the previous version from 2010.
In patients with stable CHD, documentation of ischemia is critical. Invasive measurement of intracoronary fractional flow reserve (FFR) allows assessment of the hemodynamic relevance of the corresponding stenosis (class 1 recommendation when noninvasive evidence of ischemia is not available). Revascularization of left main stenoses, proximal LAD(“left anterior descending artery”) stenoses, and stenoses in 2- or 3-vessel disease with impaired left ventricular function is recommended for prognostic reasons, provided that lesion-specific evidence of ischemia (by FFR or noninvasively) is available. Revascularization is also recommended for stenoses that cause an ischemic area of 10% or greater of the left ventricle or that involve symptoms and ischemia that are not resolvable with medical therapy.
Based on the long-term data from SYNTAX (a study that showed no mortality difference between CABG and PCI for most subgroups at five years), substantial changes in recommendations for each revascularization method are also emerging. In addition, there is growing evidence on the new drug-eluting stents. PCI is now considered equivalent to bypass in lesions for which surgery was previously recommended (class I recommendation for 1- and 2-vessel disease with proximal LAD involvement, left main stem stenosis, and 3-vessel disease with a SYNTAX score of ≤22).
Hypertrophic cardiomyopathy
New guidelines were also presented on the rare condition of hypertrophic cardiomyopathy (HCM), defined as a thickening (≥15 mm) of the left ventricle usually inherited in an autosomal dominant manner. In particular, it emphasizes the multidisciplinary approach (imaging, genetics, percutaneous and surgical interventions, pharmacology).
A new continuous risk score to predict sudden cardiac death is introduced (also available via app for smartphones). In general, the risk of sudden cardiac death in HCM is not as high (5%/5 years), but it can vary widely (0-30%). The risk score is based on maximal thickening, left atrial diameter, maximal left ventricular outflow tract (LVOT) gradient, family history, ventricular tachycardia, unexplained syncope, and age. The 5-year risk of sudden cardiac death should be collected at the initial evaluation and then every one to two years (as well as when there are changes in clinical status). Defibrillator implantation should be considered with a 5-year risk ≥6% and a life expectancy of >1 year.
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First-line therapy consists of nonvasodilating beta-blockers. Septal reduction therapies to improve symptoms are recommended in patients with a resting or maximally provoked LVOT gradient of ≥50 mmHg in NYHA class III-IV despite maximally tolerable medical therapy.
Aortic diseases
The new guidelines for the diagnosis and treatment of aortic diseases (e.g., aortic dissection, intramural hematoma, penetrating ulcer, thoracic and abdominal aneurysms, traumatic injury, and lesions associated with a bicuspid aortic valve) encompass all acute and chronic conditions of the thoracic and abdominal aorta in adults, filling a gap that previously existed between several other ESC guidelines. Although many aortic diseases are asymptomatic, acute aortic syndromes are among the most dangerous clinical conditions. Because they can be insidious in their clinical course, various screening programs are currently being developed. The differential diagnosis between ACS and aortic dissection is also challenging. However, accurate diagnosis using imaging techniques is critical for therapy. Surgery is usually required, although endovascular therapies are becoming increasingly important. Hybrid approaches are also often useful.
Also considered are genetic and congenital aortic diseases, where preventive measures could reduce the likelihood of clinical events. Aortic disease in the elderly population are another focus of the guidelines.
Non-cardiac operations
Surgeries during which heart disease is a potential source of complications account for approximately 30% of the estimated 19 million surgeries performed per year across Europe. The new ESC and ESA guidelines provide an overview of cardiovascular assessment and management in non-cardiac surgery.
Cardiac complications may occur, for example, in documented or asymptomatic CHD, left ventricular dysfunction, and valvular heart disease if surgery is associated with prolonged hemodynamic and cardiac stress.
The new guidelines recommend a step-by-step approach to practice. In addition to clinical risk factors and test results, the estimated burden of the planned surgery should also be evaluated. An individualized cardiac risk assessment is necessary to assess the potential for coronary intervention or initiation of drug therapy. Clarify which patients will benefit from cardiac assessment, coronary revascularization, or preoperative cardiovascular therapy. Specifically, preoperative prophylactic coronary revascularization has been critically reviewed and is rarely indicated. Specific surgical and anesthetic techniques can improve the patient’s perioperative condition. Evidence on optimal cardiac care in the surgical setting has been largely lacking from randomized trials; therefore, data from the nonoperative setting are currently relied upon more heavily.
Like the earlier 2009 version, this update is divided into different stages: preoperative risk evaluation, risk reduction strategies, perioperative management, and monitoring. Various clinical situations such as heart failure, arterial hypertension, valvular heart disease, arrhythmias, renal disease, cerebrovascular and pulmonary disease, and peripheral arterial occlusive disease and congenital heart disease are discussed individually.
Source: ESC Congress, August 30 – September 3, 2014, Barcelona
CARDIOVASC 2014; 13(5): 28-31
